Although President Trump and House Republican leaders held a White House Rose Garden ceremony to celebrate House passage of legislation to partially repeal the Affordable Care Act (ACA), the prospects for actual enactment of the bill into law are highly uncertain. The American Health Care Act of 2017 (HR 1628), approved by the House May 4, 2017 on a 217 to 213 vote, generally follows the contours of an earlier version of the bill pulled from House consideration in March due to insufficient support. To gain the votes of more conservative Republican members, the updated version of the bill makes it easier for states to obtain federal approval to waive various ACA requirements, including provisions related to essential health benefits and premium protection for individuals with pre-existing medical conditions, in order “to encourage fair health insurance premiums.” In response to concerns about the potential impact of state waivers on rates for individuals with pre-existing conditions, leadership agreed to add $8 billion over five years to offset increased costs to such consumers – an amount which critics contend is insufficient to meaningfully reduce premiums. The revised legislation also retained steep cuts in Medicaid spending and is still expected to result in a significant increase in the uninsured population. Adding to the uncertainty of the impact of the legislation is the lack of a Congressional Budget Office (CBO) score for the revised bill; CBO does not expect to have an updated score until the week of May 22.

The action now moves to the Senate, where lawmakers from both parties have indicated that they intend to significantly revise the House plan, if not start from scratch. Recent news of major health plans exiting the ACA insurance exchanges keeps the spotlight on the uncertain future of the ACA. Given that senators are awaiting the CBO score and Senate parliamentary guidance on the scope of policy changes that can be made under archaic Senate procedural rules, however, formal Senate action is likely weeks or even months away. A House-Senate conference committee will be likely if the Senate does pass a health care measure, further delaying when a bill might reach the President’s desk.